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Journal of Orthopaedic Case Reports Jun 2024Central hip dislocations are rare orthopedic injuries, and their concomitant occurrence with ipsilateral knee dislocations is an even rarer phenomenon. We present a...
INTRODUCTION
Central hip dislocations are rare orthopedic injuries, and their concomitant occurrence with ipsilateral knee dislocations is an even rarer phenomenon. We present a unique case of central hip dislocation along with ipsilateral knee dislocation and additional fractures involving the lateral condyle of the left tibia and patella. This complex injury pattern resulted from a severe road traffic accident, necessitating operative management to address the multiple musculoskeletal injuries. Ultimately, femoral head avascular necrosis (AVN) developed, leading to the need for total hip replacement (THR).
CASE REPORT
A 28-year-old male was involved in a high-impact road traffic accident, leading to central hip dislocation, ipsilateral knee dislocation, and fractures of the lateral condyle of the left tibia and patella. The patient was promptly assessed, and operative intervention was initiated. Closed reduction and internal fixation with K-wires were performed for the fractures of the lateral condyle of the left tibia and patella. For the central hip dislocation, open reduction was achieved using a 9-hole RECON plate. Following the procedures, a long leg slab was applied for 6 weeks to facilitate optimal healing.Postoperatively, at the 6-week mark, K-wires were removed, and the patient commenced physiotherapy with partial weight-bearing permitted. However, during the rehabilitation phase, the patient reported instability in his left knee. Magnetic resonance imaging revealed an avulsion fracture of the posterior cruciate ligament (PCL) from its tibial attachment site and a complete anterior cruciate ligament (ACL) tear. It was observed that the femoral head had developed AVN. This complication necessitated further intervention, leading to the performance of a THR.
DISCUSSION
This case underscores the challenges and complexities associated with managing central hip dislocation and ipsilateral knee dislocation with multiple fractures. The post-operative instability of the knee, diagnosed as an avulsion fracture of the PCL and complete ACL tear, necessitated additional intervention. The patient subsequently underwent PCL reconstruction using a semitendinosus graft, highlighting the importance of a comprehensive approach to address the diverse musculoskeletal injuries resulting from high-impact trauma.
CONCLUSION
The successful management of central hip dislocation and ipsilateral knee dislocation with associated fractures requires a multidisciplinary approach, incorporating timely surgical intervention, rigorous rehabilitation, and vigilant post-operative monitoring to address potential complications. This case emphasizes the need for ongoing clinical assessment and imaging studies to identify and manage secondary injuries that may manifest during the recovery phase. In addition, it highlights the development of femoral head AVN, ultimately leading to the necessity for THR.
PubMed: 38910986
DOI: 10.13107/jocr.2024.v14.i06.4524 -
Hand (New York, N.Y.) Jun 2024Periosteal sleeve fractures, or avulsions of cartilage and/or periosteum with or without an osseous fragment in skeletally immature individuals, are notoriously easy to...
Periosteal sleeve fractures, or avulsions of cartilage and/or periosteum with or without an osseous fragment in skeletally immature individuals, are notoriously easy to miss and a high index of suspicion is necessary for accurate diagnosis and treatment. While periosteal sleeve avulsion fractures are classically reported in the patella, they have also been reported in the shoulder, clavicle, and elsewhere in the knee. However, no published reports exist for a periosteal sleeve avulsion fracture in the hand. This case details the first reported instance of such an injury involving a thumb metacarpal in a 3-year-old boy, treated with open reduction and percutaneous pinning of the thumb metacarpal.
PubMed: 38910454
DOI: 10.1177/15589447241260074 -
Journal of ISAKOS : Joint Disorders &... Jun 2024Robotic-tools have been developed to improve planning, accuracy and outcomes in total knee arthroplasty (TKA). The purpose of this study was to describe and illustrate a...
OBJECTIVES
Robotic-tools have been developed to improve planning, accuracy and outcomes in total knee arthroplasty (TKA). The purpose of this study was to describe and illustrate a novel technique for assessing the patellofemoral (PFJ) in TKA using an imageless robotic platform.
METHODS
A consecutive series of 30 R-TKA were undertaken by a single-surgeon utilising the described technique. A technique to dynamically assess the PFJ intra-operatively, pre and post implantation was developed. A full set of data from 9 cases was then collected and reviewed for analysis. A series of dynamic PFJ tracks collected intra-operatively pre and post implantation are presented. Furthermore, a full assessment of PFJ over and under-stuffing through a 90° arc of flexion is illustrated. Finally, a pre and post centre of rotation for the PFJ was defined and measured.
RESULTS
The described technique was defined over a series of 30 R-TKA using the described robotic platform. Nine cases were analysed to determine what data could be measured using the robotic platform. Intra-operative real-time data allowed a visual assessment of PFJ tracking through a range of motion of 0° to 90° flexion pre and post-implantation. PFJ over and under-stuffing was also assessed intra-operatively through a range of motion of 0° to 90° flexion. Post operative analysis allowed a more detailed study to be performed, including defining a pre and post implantation centre of rotation (COR) for the patella. Defining the COR allowed the definition of a patella plane. Furthermore, patella mediolateral shift in full extension, and end flexion could be measured.
CONCLUSION
Intra-operative assessment of the PFJ in TKA is challenging. Robotic tools have been developed to improve measurement, accuracy of delivery and outcomes in TKA. These tools can be adapted in novel ways to assess the PFJ, which may lead to further refinements in TKA techniques.
PubMed: 38909904
DOI: 10.1016/j.jisako.2024.06.006 -
Journal of ISAKOS : Joint Disorders &... Jun 2024Female gender is one of the commonly mentioned risk factors for anterior knee pain (AKP), among a spectrum of other factors including anatomical, biomechanical,...
Female gender is one of the commonly mentioned risk factors for anterior knee pain (AKP), among a spectrum of other factors including anatomical, biomechanical, hormonal, behavioral, and psychological elements contributing to its development. Despite the focus on individual risk factors, there's a notable gap in comprehending how gender influences and interacts with other risk factors. The objective of this review was to identify and emphasize the connections between these interactions, gender-related risk factors for AKP, and the potential mechanisms that explain their associations with other risk factors, aiming to aid in the creation of precise prevention and treatment approaches. Gender influences the majority of risk factors for AKP, including anatomical, biomechanical, hormonal, behavioral, and psychological factors. Women have on average smaller patellae, higher patellofemoral cartilage stress and for AKP, disadvantageous trochlear morphology, ligament and muscle composition and unfavorable neuromuscular control pattern. In contrast, men show on average an increased ability to strengthen their hip external rotators, which are both protective against AKP. Particularly in kinetic and kinematic analysis, men have been shown to have a distinctly different risk factor profile than women. Sex hormones may also play a role in the risk of AKP, with estrogen potentially influencing ligamentous laxity, increasing midfoot loading and affecting neuromuscular control of the lower extremities and testosterone positively affecting muscle mass and strength. The higher incidence of AKP in women is likely due to a combination of slightly increased risk factors. Although all risk factors can be present in both men and women and the holistic evaluation of each individual's risk factor composition is imperative regardless of gender, knowing distinctive risk factors may help with focused evaluation, treatment, and implementing preventive measures of AKP.
PubMed: 38908481
DOI: 10.1016/j.jisako.2024.05.014 -
Journal of Pediatric Orthopedics Jun 2024Patellar height changes after tibial tubercle osteotomy (TTO) have not yet been described. We aimed to evaluate whether TTO ± medial patellofemoral ligament...
Tibial Tubercle Osteotomy With and Without Medial Patellofemoral Ligament Reconstruction in Adolescent Patients Leads to Decrease in Patellar Height and Patella Tendon Length.
OBJECTIVE
Patellar height changes after tibial tubercle osteotomy (TTO) have not yet been described. We aimed to evaluate whether TTO ± medial patellofemoral ligament reconstruction (MPFL-R) influences patellar height and tendon length, hypothesizing that TTO would decrease patellar height and tendon length.
METHODS
A retrospective review was performed of skeletally mature adolescents (<18 y) receiving primary anteromedialization or medialization TTO ± MPFL-R. Patients with at least 6 months of radiographic follow-up were included in the study. Pre and postoperative patellar heights were assessed on lateral, weight-bearing, and flexion (30 to 70 degrees) radiographs using the Blackburne-Peel Index (BPI), Caton-Deschamps Index (CDI), and Insall-Salvati Ratio (ISR). Subgroup analyses were performed to compare patellar height changes in patients with preoperative patella alta, norma, and baja, as well as between patients undergoing medialization and anteromedialization TTO. Data were analyzed for normality using a Shapiro-Wilk test, and paired-sample t tests were performed.
RESULTS
Forty-nine knees were included (mean age: 15 y; range: 12 to 17). A significant decrease in mean patellar height after TTO ± MPFL-R was observed across all measures: BPI (0.12, P = 0.000783), CDI (0.08, P = 0.01062), and ISR (0.15, P = 0.00000075). Patellar tendon length decreased by 2.26 mm ( P = 0.001272). Subgroup analyses demonstrated a decrease in mean patellar height across all 3 measurements ( P < 0.001; BPI, CDI, and ISR) for patients with preoperative patella alta but not patella norma or baja. Additional subgroup analysis showed a patellar height decrease using BPI (0.15, P = 0.004583) and ISR (0.14, P = 0.0002806) for patients receiving medialization TTO but not anteromedialization. The anteromedialization cohort did not demonstrate patellar height change using BPI and CDI; ISR demonstrated a decrease (0.10, P = 0.00917).
CONCLUSIONS
Mean patellar height and tendon length decreases after TTO ± MPFL-R in skeletally mature, adolescent patients. Subgroup analyses suggest these changes occur in patients with preoperative patella alta and/or patients who undergo medialization TTO. These data suggest that some distalization in patellar positioning may be achieved without formal distalization osteotomy.
PubMed: 38907594
DOI: 10.1097/BPO.0000000000002753 -
Danish Medical Journal Jun 2024In orthopaedics, anterior cruciate ligament (ACL) reconstructions are among the most common surgical interventions. Two methods are preferably used: autografts from the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
In orthopaedics, anterior cruciate ligament (ACL) reconstructions are among the most common surgical interventions. Two methods are preferably used: autografts from the hamstring tendon (HT) or patella tendon (PT). The purpose of this meta-analysis was to compare these two methods when returning to sports.
METHODS
Eleven studies were included based on a literature search conducted in PubMed. The primary outcome was return to preinjury sport level in athletes. Post-operative results such as the Lysholm score, the International Knee Documentation Committee (IKDC) subjective score, the Tegner Activity Score and KT-1000 arthrometry and autograft re-rupture rates were analysed as secondary outcomes.
RESULTS
The analysis showed no significant difference in return to preinjury sports level at a two-year follow-up between patients operated with hamstring or patella autograft. Considering the secondary outcomes, no significant differences were recorded in Lysholm score, IKDC score or re-rupture rate. The Tegner Activity Scale demonstrated a significantly higher activity level in the PT group than in the HT group (OR 0.79, p = 0.003). At the two-year follow-up, the KT-1000 arthrometer analysis also showed a significant difference in laxity, which was higher for the HT autografts (OR -0.31, p = 0.02).
CONCLUSION
This study showed no significant differences between hamstring and patella autografts. Even so, the choice of method when operated for ACL rupture remains crucial for the individual and should be a weighted decision made jointly by the patient and the physician.
Topics: Humans; Return to Sport; Anterior Cruciate Ligament Reconstruction; Hamstring Tendons; Patellar Ligament; Anterior Cruciate Ligament Injuries; Autografts; Transplantation, Autologous; Treatment Outcome
PubMed: 38903025
DOI: 10.61409/A09230599 -
Archives of Orthopaedic and Trauma... Jun 2024The radiographical assessment of patella height has historically been performed using X-Ray. The aim of this study was to evaluate a new method for the assessment of...
INTRODUCTION
The radiographical assessment of patella height has historically been performed using X-Ray. The aim of this study was to evaluate a new method for the assessment of patella height using MRI and to assess the correlation with the X-Ray based assessment.
MATERIALS AND METHODS
159 patients who had both lateral radiographs and MRI images were included. Parameters measured included traditional radiographical CDI, MRI-based CDI, and TT-TG distance. On the basis of the TT-TG, the patients were divided into 2 groups. Two different methods were used to assess CDI using MRI: using a single slice image, and an alternative technique using two different cross-sectional images. The correlation of the two measurement methods was assessed using Pearson's correlation coefficient. The intraclass correlation coefficient (ICC) was determined from the measurements of the two investigators.
RESULTS
The average TT-TG distance was 11.6 mm (± 4.6). In patients with a TT-TG < 15 mm, both measurement methods showed comparable correlation with measurements on X-Ray. In patients with a TT-TG of > 15 the the new cross-sectional imaging method showed higher correlation with traditional X-Ray assessment compared to CDI assessment using the traditional single slice method (r = 0.594, p < 0.001 vs. r = 0.302, p = 0.055).
CONCLUSIONS
The assessment of CDI on MRI using a cross-sectional imaging method has a better correlation with traditional X-Ray assessment of CDI than single-slice assessment. This is particularly true in patients with elevated TT-TG and as such should be preferentially used in the assessment of Patellar height in this cohort.
PubMed: 38900292
DOI: 10.1007/s00402-024-05403-5 -
Journal of ISAKOS : Joint Disorders &... Jun 2024Patellofemoral osteoarthritis (PFOA) is the result of degeneration and loss of articular cartilage of the patella and trochlea, and is a common cause of anterior knee...
Patellofemoral osteoarthritis (PFOA) is the result of degeneration and loss of articular cartilage of the patella and trochlea, and is a common cause of anterior knee pain. PFOA is triggered by insufficient adaptation to overload of the articular cartilage of the PF joint created by abnormal biomechanics. It is important to understand the pathophysiology and natural history to make the diagnosis and to plan treatment. Innate factors including malalignment, patellar instability, kinematic disorders, and acquired factors like trauma, obesity, and endocrine diseases have been found to be causes of PFOA. Genetic predisposition is also described as a contributing cause but without much scientific evidence. The diagnosis will be based on clinical manifestations, such as anterior knee pain aggravated by overloading activities, identification of risk factors, exclusion of referred pain from other pathologies, followed by a systematic and structured physical examination. Imaging will be useful for assessing the presence of early osteoarthritis in the other compartments, for classification of the PFOA, and to identify features to establish an adequate treatment. This paper discusses varying management options for different causes of patellofemoral disease and explains the complexity of the PF joint and its often poorly understood biomechanics.
PubMed: 38897413
DOI: 10.1016/j.jisako.2024.06.004 -
The American Journal of Sports Medicine Jun 2024Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its...
Early Postoperative Rapid Rehabilitation Yields More Favorable Short-term Outcomes in Patients Undergoing Patellar Realignment Surgery for Recurrent Patellar Dislocation: A Prospective Randomized Controlled Study.
BACKGROUND
Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its safety and effectiveness is lacking.
PURPOSE
To compare the short-term postoperative outcomes of early rapid rehabilitation with those of conservative rehabilitation in patients with RPD.
STUDY DESIGN
Randomized controlled trial; Level of evidence, 2.
METHODS
A total of 50 patients with RPD who underwent tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction were enrolled between January 2018 and February 2019. Postoperatively, the patients were randomly assigned to either the early rapid group (rapid group; n = 25 patients) or the conservative group (control group; n = 25 patients) for rehabilitation training. The rapid group underwent faster progression in weightbearing and range of motion (ROM) training. Knee joint functional scores, ROM, bilateral thigh circumference differences, and imaging data were recorded preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively for comparison. Postoperative complications were recorded over the 24-month follow-up period.
RESULTS
The baseline data did not significantly differ between the 2 groups. Postoperatively, compared with the control group, the rapid group had higher Tegner scores at 6 weeks and 3 months; higher Lysholm scores at 3 and 6 months; higher International Knee Documentation Committee scores at 6 weeks, 3 months, and 12 months; better ROM; and smaller bilateral thigh circumference differences at 24 months ( < .05 for all). However, no differences were observed in the Tegner, Lysholm, and International Knee Documentation Committee scores at 24 months postoperatively. At the 6-week and subsequent follow-up visits, the Caton and Insall indices were lower in the control group than in the rapid group ( < .01 for all). Moreover, compared with the control group, the rapid group had a lower incidence of patella baja at 24 months (0% vs 17%) and fewer complications during the whole follow-up period ( < .01).
CONCLUSION
Early rapid postoperative rehabilitation appears to be safe and effective for patients who undergo tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction to treat RPD. In the short term, this approach was shown to be more advantageous than conservative rehabilitation in improving functional scores, allowing an earlier return to daily activities, although the lack of difference at 24 months implies no long-term benefits. In addition, it potentially helped to prevent the occurrence of complications, including patella baja.
REGISTRATION
ChiCTR1800014648 (ClinicalTrials.gov identifier).
PubMed: 38884318
DOI: 10.1177/03635465241254524 -
Orthopaedic Journal of Sports Medicine Jun 2024Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic...
BACKGROUND
Medial patellar facet lesions have been well-described in the setting of patellar instability. However, relatively little is known about risk factors for atraumatic medial patellar facet lesions.
PURPOSE/HYPOTHESIS
To identify clinical and radiographic risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability. It was hypothesized that a posterior tibial tubercle relative to the trochlear groove would be a risk factor for atraumatic medial patellar facet lesions.
STUDY DESIGN
Case-control study; Level of evidence, 3.
METHODS
A total of 37 patients with atraumatic medial patellar facet lesions were matched by age, sex, and body mass index with 37 control patients without a history of patellofemoral dysplasia. Demographic and imaging characteristics were compared between groups. Plain radiography was used to evaluate Wiberg type, and magnetic resonance imaging was used to calculate Caton-Deschamps index, tibial tubercle-trochlear groove distance, trochlear facet asymmetry ratio, patellotrochlear index, sulcus depth, patellar bisect ratio, and tibial tubercle height. Statistically significant variables from univariate analysis were used as inputs to the multivariate regression model to assess independent risk factors.
RESULTS
There were no differences between groups with respect to Wiberg type, Caton-Deschamps index, tibial tubercle-trochlear groove distance, sulcus depth, or patellotrochlear index ( > .05 for all). The medial facet lesion group had a larger medial trochlear facet (trochlear facet asymmetry ratio, 0.72 ± 0.11 vs 0.60 ± 0.09; < .001), a more medial-lying patella in the trochlear groove (patellar bisect ratio, 0.57 ± 0.06 vs 0.55 ± 0.07; = .035), and a more posterior tibial tubercle relative to the trochlear groove (tibial tubercle height, -3.13 ± 5.21 vs -0.23 ± 5.93 mm; = .030) compared with the control group. Multivariate regression analysis identified trochlear facet asymmetry and tibial tubercle height as independent risk factors for medial patellar facet lesions (relative risk = 97.3 [95% CI, 14.9-635.1], < .001 and relative risk = 0.95 [95% CI, 0.92-0.98], = .004, respectively).
CONCLUSION
A relatively larger medial trochlear facet and a more posterior tibial tubercle relative to the trochlear groove were found to be risk factors for medial patellar facet lesions in patients without a history of trauma or patellar instability.
PubMed: 38881850
DOI: 10.1177/23259671241255681